Rationing

I met a urologist from another city recently. Since it had been a much discussed issue recently, I asked him what he thought about PSA testing. His answer was immediate.
"I think PSA testing has been proven to save lives, and I have no doubt it should be done routinely."

When I mentioned the recent recommendation that prostate cancer screening be stopped after a man reaches 70, his faced turned red. "That report is clearly an attempt by the liberal media to set the stage for rationing of healthcare. It was a flawed study and should not be taken as the final say on the matter." He went on to recount cases of otherwise healthy 80 year-old men who developed high-grade prostate cancer, suffered, and died.

I chose not to debate him on the subject, but did point out that his view was that of one who sees the worst of the worst. I personally can recall less than ten patients who died of prostate cancer in the fifteen years I have practiced. My view is one that sees a non-diseased general public, and not worst-case scenarios. I also didn't point out that even the American Cancer Society stopped pushing the test and states, and does not think as highly of the evidence as he does: "Using the PSA test to screen men for prostate cancer is controversial because it is not yet known for certain whether this test actually saves lives." (1).

But I digress. What really struck me in the discussion was the way he pulled out the idea of rationing as the end-all hell for American healthcare. It is regularly used as a scare tactic for those who advocate a "free market approach" to healthcare. They point to the UK and Canada where people are denied cancer treatment or delayed repair of a ruptured disc resulting in permanent paralysis. Rationing healthcare seems a universal evil, and any step that is made toward cotroling cost is felt by some to be a push of the agenda of the Obama administration toward universal health coverage and ultimately rationing.

So what exactly is so bad about rationing? The word itself refers to an individual being given a set amount of a limited resource, above which none will be available. In healthcare, the idea is that each American is given only a set amount of coverage for care and above that they are left to fend for themselves. Those who are either go over their limit or are felt to have a less legitimate claim on a scarce resource will be denied it. This is especially scary for those who are the high-utilizers (the uninsurable that I have discussed previously), as they will use up their ration cards much faster than others. I certainly understand this fear.

But are all limitations put on care really a step toward rationing? Are limits put on care a bad thing? The answer to that is simple: DUH! Of course not! Of course there need to be limits on care! Without control over what is paid for, the system will fall apart. Here's why:

Limited Resources - Not only are our resources limited, they need shrinking. The overall cost of our system is very high and has to be controlled somehow. Different interests are competing for resources, and by definition whoever doesn't win, doesn't get paid. This means that someone needs to prioritize what is a necessity and what is not.

Lack of personal culpability by patients - with both privately and publicly funded insurance, the actual cost to the patient is defrayed. They are not harmed by unnecessary spending, so they don't try to control it. Only uninsured patients are painfully aware of the cost of unnecessry tests.

Lack of personal culpability by doctors - If I order an unnecessary test or expensive drug, I am not harmed by the waste. For example, it is common practice by emergency physicians in our area to get a chest x-ray on children with fever. Most of this is related to defensive medicine which is understandable in the ER, but clinically the test is often not warranted. Yet the emergency physicians are not really affected by this waste, and the hospital and radiologists are actually rewarded by it if the insurance company pays for it (which they do).

Incentives for other parties - As I just said, hospitals and radiologists have incentives to have wasteful procedures done. The urologist I spoke to has a huge financial stake in the continuation of PSA testing, as it generates enormous business for him. Drug companies want us to order their more expensive drugs than the generic alternatives. This doesn't mean any of them are wrong, but they sure as heck won't fight waste if it harms them financially to do so.

When I was a physician starting out, the insurance companies would pay for pretty much any drug I prescribed. At that time there were very expensive branded anti-inflamatory drugs that were aggressively pushed by the drug companies. When the first drug formulary came around, the first thing that happened was that they forced me to use generic drugs of this type. Before, there was no reason not to prescribe a brand, I had samples, and they were a tiny bit more convenient. But when I changed there was really no negative effect on my patients.

One of our local hospitals just built a huge new cardiac center. Statistically, our area is a very high-consumer of coronary artery stents compared to the national average. Yet there are many cases in which an asymptomatic person will get a stent placed simply because they have abnormalities on their cardiac catheterization. Logically this may make sense, but the data do not suggest that these people are helped at all. Do you think that the hospital wants these procedures halted? Do you think the cardiologists do? Yet if they are truly unnecessary, shouldn't they be stopped? Couldn't the $200 million they spent on their state-of-the-art facility be used in better ways? Someone has to be looking at this and making sure the money spent is not wasted.

Without cost control a business will fail, and the same goes for our system. Yet any suggestion at the elimination of clinically questionable procedures is met with cries of rationing. Right now we are not at the point of rationing, and the act of trying to control cost by eliminating unnecessary procedures does not necessarily imply that the end goal is rationing. The end goal is to spend money on necessary procedures instead of waste. I sincerely doubt there is a left-wing conspiracy to push us to deny care where it is needed. I doubt that the American Cancer Society is in favor of rationing.

Let's just spend our money wisely. It's just common sense; not an evil plot.